care plan help..please!!

hi I need help with my care i finished it already but my professor told me that i have to make some changes in it but i do not know what i did wrong.

Where's your care plan and the professor's comment's? All you posted was the information about the case scenario. I can't tell you where you are making errors or explain them to you without that information.

although you didn't list your professor's comments, i see major problems with your care plan. three of your diagnoses are absolutely incorrect and do not even reflect the assessment data. you diagnosed only one actual nursing problem; i found 4 actual nursing problems. probably 75% of this care plan needs to be totally re-written. i will not address the classification of subjective and objective data. you can do that. i am more concerned about how you are determining, critical thinking and diagnosing the nursing problems. we use the nursing process to do that.

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
   • a physical assessment of the patient
     
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
     
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
     
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     
     • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
       

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
    

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration
    

  [*]how to write goal statements: https://allnurses.com/forums/2509305-post158.html

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

    [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology [color=#003300]- i want you to look up everything you can find about congestive heart failure because when i read through the scenario that is what was screaming out to me that was going on with this patient. this guy is in serious trouble with his heart today. you need to know what the pathophysiology of chf is, its signs and symptoms, complications and how physicians treat it.

• [color=#003300]history of hypertension with poor control, despite taking atenolol 10mb every day - a beta blocker and antihypertensive that also slows the sa node discharge and will slow the heart rate. one of its side effects is that it can cause congestive heart failure.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data [color=#003300]- this is the list i compiled from the scenario

tachycardic

• p = 112
  
• s3 gallop
  
• bp = 154/108
  
• sudden swelling in his feet states, "i had an eight pound weight gain overnight"
  
• feet and ankles have 3+ pitting edema
  
• chest x-ray: left ventricular hypertrophy
  
• comes to his primary care provider complaining of dyspnea
  
• r = 26
  
• expiratory crackles in the bases of both lung
  
• a dry, hacking cough
  
• exertion ("i get so out breath when i walk to the corner of our street")
  
• fatigue
  
• tsh: 2.5 uu/ml (2-10uu is normal)
  
• "takes care of her because she has had several mild strokes" (wife)
  
• have one adult child in the area, who comes to visit them every week
  
• live in the area over 30 years and have many friends in the nearby region

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

1. decreased cardiac output r/t altered stroke volume secondary to cardiac congestion aeb tachycardia of 112, an s3 gallop, blood pressure of 154/108, sudden swelling of 3+ edema in his feet with pitting, chest x-ray that shows left ventricular hypertrophy and patient statement that "i had an eight pound weight gain overnight". (this are all symptoms of congestive heart failure which has resulted in altered stroke volume, one of the components of cardiac output. you can read about cardiac output and congestive heart failure on these websites:
   • http://www.nsbri.org/humanphysspace/focus2/student1.html,
     
   • http://en.wikipedia.org/wiki/cardiac_output,
     
   • http://cvphysiology.com/heart%20failure/hf002.htm
     • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=09

• decreased cardiac output

[*]activity intolerance r/t imbalance between oxygen supply and demand aeb fatigue and statement by patient that on exertion "i get so out breath when i walk to the corner of our street". (this diagnosis is about the patient having signs and symptoms approaching or actually getting hypoxia, so your scientific rationale is to find references that list the signs and symptoms of oxygen deprivation and hypoxia. fatigue is a long-term effect of hypoxia to the tissues.)

• http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=01
  
• activity intolerance

[*]ineffective airway clearance r/t retained secretions aeb dyspnea with respiratory rate of 26, expiratory crackles in the bases of both lungs and a dry, hacking cough. (this is your basic mucus trapped in the lung that the patient can't cough out. either he is too tired or weak or there is so much gunk there it is overwhelming. check your textbook under respiratory problems or the merck manual. many times these secretions are just so thick they are hard for the patient to cough out.)

• http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=02
  
• ineffective airway clearance

[*]anxiety r/t threat to role aeb statement that he "takes care of her [wife] because she has had several mild strokes". (this is worry about not being able to do his responsibility as a husband. for rationale on role performance you may need to look at erickson's developmental stages would be my suggestion: middle-age adult (generativity vs stagnation: seeks satisfaction through productivity in career, family, and civic interests); older adult (integrity vs despair: reviews life accomplishments, deals with loss and preparation for death))

• http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=03
  
• anxiety

for the scientific rationale to support the use of these diagnoses you can use the websites referenced. the online merck manual has a lot of good information on cardiac and respiratory subjects (http://www.merck.com/mrkshared/mmanual/sections.jsp). i've also included weblinks to nursing diagnosis pages for these diagnoses that have some explanations about the diagnoses as well as some suggestions for interventions. so, you have several places to go for rationales now.

remember that your nursing interventions must address the items following the "aeb" part of each nursing diagnostic statement. then, the goal for that particular diagnosis must be what you predict should happen as a result of your interventions being followed. it should all make sense when the diagnosis, interventions and goals are read together.